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SLE arthralgia: 1 in 4 have inflammation not detected by clinical instruments

The existing classification of musculoskeletal (MSK) symptoms of systemic lupus erythematosus (SLE) based on joint swelling is inaccurate to guide patient selection for biologic therapy, according to a study published in Rheumatology.

The cross-sectional observational study was conducted in 112 consecutive SLE patients with active inflammatory MSK symptoms attending centres in Leeds and Southampton, along with 24 asymptomatic SLE control participantss.

Participants were clinically assessed using the British Isles Lupus Assessment Group (BILAG) disease activity index, SLE Disease Activity Index (SLEDAI), joint counts, and patient and physician visual analogue score along with routine laboratory tests and ultrasound (US) examination of 2 hands and wrists for synovitis and tenosynovitis.

Overall, 68% (60/88) of symptomatic patients were found to have US inflammation (grey scale ≥2 and/or PD ≥1 or tenosynovitis) compared with 17% (4/23) of asymptomatic patients.

In symptomatic patients, BILAG A or B-defined inflammation was identified in 38% and SLEDAI-defined inflammation was present in 32%. BILAG A/B had sensitivity of 56% (95% CI, 41%-69%) and specificity of 89% (95% CI, 72%-96%) for US-confirmed inflammation. SLEDAI-MSK criterion had sensitivity and specificity of 44% (95% CI, 31%-59%) and 89% (95% CI, 72%-96%), respectively.

In patients with inflammatory symptoms, 27% had abnormal US findings but no clinically swollen joints (subclinical inflammation) and 35% had no clinical or US inflammation.

The authors concluded that a large proportion of SLE patients with MSK symptoms have clinically meaningful inflammation that is only identifiable with US.

Consequently, they advise that the “existing classification of MSK SLE using disease activity instruments based on joint swelling is inaccurate to guide patient selection for clinical trials, biologic therapy, or treat-to-target protocols”.


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